Cell 2 Soul: The Humane Health Care Blog

What Matters To Me

The question “What matters to me?” (WMTM) allows patients to tell physicians and other care providers about their interests, values, and preferences, as full humans, not just recipients of care. This philosophy is particularly hard for providers to follow during consultations lasting only 10 to15 minutes.

Dr. Sosena Kebede and I have designed a questionnaire to enable us to learn more about what our patients think about this issue.  This is a work in progress.  If you want to see and fill out our questionnaire please access this link.

WMTM has been looked at from a different perspective in Scotland and British Columbia.  Those programs can be accessed at: Download What Matters To Me Programs

Diagram from Scottish Questionnaire

 

 

 

 

I.C.U. Syndrome

My I.C.U. Patient Lived. Is That Enough?
By Daniela J. Lamas NYT April 2, 2017
[This is a fine article by Dr. Lamas, a Critical Care physician in Boston.  Anything she writes is worth reading]

FULL TEXT

ONE morning I was at a support group for patients who had survived a critical illness and their family members. It seems simple — a few doctors, a social worker, a psychiatrist, former patients and their husbands and wives, a conference room, pastries, coffee.

As many as one in three patients sick enough to require a ventilator might develop symptoms of post-traumatic stress disorder. Anxiety and depression are equally common, if not more so. The name for the constellation of symptoms often experienced by survivors of critical illness — post-intensive care syndrome.

As I.C.U. doctors, we can learn from our patients and their families and they can learn from one another, simply by sitting in a room together and paying attention to what unfolds. [Holds true for all health care professionals]

La Maladie du Petit Papier

These are lists—of purported ailments and symptoms—carried around by a patients to share with their care-givers. We adapted this Roz Chast cartoon to illustrate what can happen to list makers.

Reference
Elpern DJ.  La Maladie du Petit Papier J Am Acad Dermatol 2007;57:170. Download Maladie du Petit Papier

 

 

Patients Prove Profitable

When is it ethical to design a health care system that caters to those who can pay? 

An old Yiddish proverb runs:  "If the rich could pay the poor to die for them, the poor would make a very good living."

Khawar Mann, OBE, a venture capitalist with the Abraaj investment group, travels around Africa scoping out hospitals to buy that seem likely to provide good returns on investments.

Private health care has been an interesting model in the U.S. which lags behind all other developed nations in outcomes.  So why is the American system now envisioned as a viable model for Africa?  Will this not just serve to widen the "health" gap between the rich and poor?

Mr. Mann says: "“Nairobi is a sweet spot for us. There is a big population that is growing. You have emerging middle incomes. And there is a massive need for health care.” (for those who can afford to pay in cash).

This in-depth NY Times article gives one much to mull over.

Patients vs. Paperwork

Patients vs. Paperwork

When Hospital Paperwork Crowds Out Hospital Care by Theresa Brown (NY Times, December 20, 2015)

Excerpts:
In the age of electronic health records, computer documentation in health care has morphed into more than an account of our work; it has replaced the work itself.

In home hospice, where I now work, the documentation is even more onerous than in the hospital and seems even more disconnected from actual patients. Hospice care is a covered benefit under Medicare, and the Centers for Medicare and Medicaid Services maintain rigid standards for documentation. They regularly withhold reimbursement if documentation is deemed incomplete or flawed.

Charting a hospice admission usually takes between two and four hours, and requires filling out a seemingly endless number of data fields — some of them defying logic.

Electronic health records present an enticingly clean and clear vision of clinical work, whereas real patients are messy, confusing and unpredictable. Sadly, all the attention given to our paperwork is taking us further and further away from the difficult truth that meeting very ill patients’ needs occurs in real time with real people, not in the paperwork about them.

Goethe wrote: “In the end, we are dependent on creatures we have made. “ This sad truth underlies Theresa Brown’s excellent Op-Ed piece on Patients vs. Paperwork.

On Listening

Ranjana Srivastava has a memorable essay in the New England Journal of Medicine about listening to patients. Her piece, entitled “Nourishment” speaks to all of us in health care.

She writes that a patient, former pastor, told her “The gift of silent communion is the greatest gift you can give someone.” She learned that with some patients “instead of listening in order to reply, I [now] listen to understand, shielded temporarily from the pressure of performance.”

This reminded me of some lines Andre Dubus wrote in a short story that described how often people confessed their problems to him “and I listened and talked a lot and and never helped anyone at all. So now if someone comes to me I offer what I know I can give: the friendship of a listening face.”* Srivastava has some remarkably insights in her Perspective piece in the November 26, 2015 New England Journal of Medicine. It’s a keeper! Download Nourishment.Srivastava

*Andre Dubus, “We Don’t Live Here Anymore” appears in the collection “Separate Flights.”

Less Medicine, More Health

7 Assumptions That Drive Too Much Medical Care 

by H. Gilbert Welch

(The following is taken from the book's introduction)

The central problem with healthcare is that too much medical care has too little value, too many people are being made to worry about diseases they don't have an are only at a low risk to get. Too many people are being tested and exposed to all the harmful effects of the testing process: the anxiety of false alarms and the vulnerability caused by ambiguous findings, not to mention the complications of diagnostic procedures.

Too many people are being given treatments they don't need or can't benefit from. Treatment interventions can have substantial physical harms such as medication reactions, surgical complications, even death

It's not lawyers who are the problem; it's economics. Physicians are paid more to do more and insurance, not the patient, foots the bill. Paying physicians a fee every time they provide a service encourages them to order more tests and procedures. Because patients are shielded from the costs by a third-party, they have little incentive to scrutinize the value of the services.

To complicate this more, the general public harbors assumptions about medical care that encourages overuse. Assumptions like the following are extant: it's always better to fix the problem, sooner is always better or it never hurts to get more information. These assumptions flow directly from information provided to the public from many sources (doctors, drug and device makers, the media, the Internet). The public winds up with assumptions that lead to an excessively optimistic view of medical care. That leads them to seek too much care.

This book is about challenging these assumptions – and helping all of us to avoid too much medical care. As a society, we have overstated the benefits of medical care and underplayed its harms. It is possible that in many cases less medicine would be better for our health.

Less Medicine, More Health gives a few simple strategies to avoid too much medical care.

What Walsh wants from medical care is a system that excels in the care and treatment of acutely ill and injured persons. This, in his opinion, is the most important activity of medical care, but is not what most medical care is about. Much of medical care doesn't reliably lead to better health.

Rx: The Quiet Revolution

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
Modern version of Hippocratic Oath

PBS April 2, 2015

In this inspiring 90-minute documentary, filmmaker David Grubin takes his camera across America to focus on the challenges and triumphs in our country’s health care delivery system. The four segments that comprise Rx: The Quiet Revolution introduce us to a diverse group of doctors, nurses, and health care professionals who are transforming the way we receive our medical care: lowering costs by placing the patient at the center of their practice.

Rx: The Quiet Revolution shows us what’s happening from Maine to Mississippi, California to Alaska.  You will see physicians, nurses and other healthcare professionals placing the patient at the center of their practice — transforming the way medical care is delivered while lowering costs and improving outcomes.

Filmmaker David Grubin brings you these compelling stories: 

• In Maine, we meet Dr. David Loxterkamp, who practices family medicine with a team of doctors working to treat patients with chronic illnesses.

• In Mississippi, a state with more diabetes cases than any other, Grubin finds a rural health clinic fighting diabetes with the aid of an electronic communications device that provides greater access to medical care, helping patients take responsibility for managing this devastating chronic disease.

• In San Francisco, Grubin visits a health care facility for seniors called On Lok, dedicated to making it possible for frail, elderly Americans in need of nursing home care to live with dignity in their own homes.
  
  
• In Alaska, the documentary follows Native Alaskans who own and operate their own health system, caring for 65,000 people across 107,000 square miles. In spite of the number of patients and the vast distances between them, they are determined to foster an empathetic relationship between patients and their health care providers.

At 90 minutes, this may seem a daunting investment in time, but Rx: The Quiet Revolution will speak to you in powerful and compelling ways.

Introducing... Theranos!

Elizabeth Holmes (born 1984) is an American chemical and electrical engineer and entrepreneur. After droppingoutof Stanford at age 19, she founded Theranos, a health technology and medical laboratory services company that is now valued at ~ $9 billion.

Homes is the subject of a curious December 15, 2014 New Yorker profile, Blood Simpler, and gave a thought-provoking TedMed talk this past September.

Who's My Doctor?

Dr. Leana Wen is an emergency physician, public health leader, and patient advocate. A professor and DIrector of Patient-Centered Care Research at George Washington University, she is an outspoken patient-advocate.

She writes: I believe that medicine has maintained its mystique for far too long, and it’s time to open the veil of secrecy and have patients and providers alike participate as equal partners. I believe that patients have to be part of every discussion that takes place in healthcare, from research to system design to medical care.

I was sent a link to a recent TED talk she gave.  It is extraordinary and should resonate with patients and some physicians.  If you have 15 minutes, please watch Leana's talk: Who's My Doctor.